Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap

Summary: Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.

[1]  J. Blair,et al.  Posttraumatic Soft Tissue Coverage of the Lower Leg for the Orthopedic Surgeon. , 2022, The Orthopedic clinics of North America.

[2]  N. Spindler,et al.  A retrospective evaluation of 182 free flaps in extremity reconstruction and review of the literature , 2022, GMS Interdisciplinary plastic and reconstructive surgery DGPW.

[3]  C. Radtke,et al.  Reconstruction of traumatic and non-traumatic lower extremity defects with local or free flaps , 2021, European Surgery.

[4]  B. Chaput,et al.  Flap Venous Congestion and Salvage Techniques: A Systematic Literature Review , 2021, Plastic and reconstructive surgery. Global open.

[5]  L. Johnson,et al.  The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot. , 2020, Clinics in podiatric medicine and surgery.

[6]  M. Jakubietz,et al.  The reverse sural artery flap– How do modifications boost its reliability? A systematic analysis of the literature , 2020, JPRAS open.

[7]  J. Yadav,et al.  Reverse sural flap – A feasible option for oncological defects of the lower extremity, ankle, and foot: Our experience from Northeast India , 2019, South Asian Journal of Cancer.

[8]  R. Khundkar Lower extremity flap coverage following trauma. , 2019, Journal of clinical orthopaedics and trauma.

[9]  A. Nathens,et al.  Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures: A Cohort Study of 140 North American Trauma Centers , 2019, Journal of orthopaedic trauma.

[10]  Shayan A. Izaddoost,et al.  Orthopedic Prosthetic Infections: Plastic Surgery Management , 2016, Seminars in Plastic Surgery.

[11]  P. Cederna,et al.  The Reverse Superficial Sural Artery Flap Revisited for Complex Lower Extremity and Foot Reconstruction , 2015, Plastic and reconstructive surgery. Global open.

[12]  Shimin Chang,et al.  Distally based perforator sural flaps for foot and ankle reconstruction. , 2015, World journal of orthopedics.

[13]  A. Juma,et al.  Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb , 2014, The open orthopaedics journal.

[14]  Ramesha Kt,et al.  Extended Reverse Sural Artery Flap's Safety, Success and Efficacy - A Prospective Study. , 2014, Journal of clinical and diagnostic research : JCDR.

[15]  Bernard T. Lee,et al.  Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis. , 2014, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[16]  A. Vijayakumar,et al.  Comparison between Peroneus Brevis Flap and Reverse Sural Artery Flap for Coverage of Lower One-Third Leg Defects , 2014 .

[17]  M. Fujioka Surgical Reconstruction of Radiation Injuries. , 2014, Advances in wound care.

[18]  O. Riedl,et al.  Anatomy of the Sural Nerve: Cadaver Study and Literature Review , 2013, Plastic and reconstructive surgery.

[19]  M. Jakubietz,et al.  The Distally Based Adipofascial Sural Artery Flap: Faster, Safer, and Easier? A Long-Term Comparison of the Fasciocutaneous and Adipofascial Method in a Multimorbid Patient Population , 2012, Plastic and reconstructive surgery.

[20]  T. Seyhan Split-Thickness Skin Grafts , 2011 .

[21]  Rod J. Rohrich,et al.  Vascular Supply of the Distally Based Superficial Sural Artery Flap: Surgical Safe Zones Based on Component Analysis Using Three-Dimensional Computed Tomographic Angiography , 2010, Plastic and reconstructive surgery.

[22]  D. Martin,et al.  Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases. , 2006, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[23]  D. Erdmann,et al.  Delayed reverse sural flap for staged reconstruction of the foot and lower leg. , 2006, Plastic and reconstructive surgery.

[24]  S. Akhtar,et al.  Versatility of the sural fasciocutaneous flap in the coverage of lower third leg and hind foot defects. , 2006, Journal of plastic, reconstructive & aesthetic surgery : JPRAS.

[25]  H. Wang,et al.  Distally Based Sural Fasciomusculocutaneous Flap for Chronic Calcaneal Osteomyelitis in Diabetic Patients , 2005, Annals of plastic surgery.

[26]  L. Levin,et al.  A Realistic Complication Analysis of 70 Sural Artery Flaps in a Multimorbid Patient Group , 2003, Plastic and reconstructive surgery.

[27]  R. M. Smith,et al.  Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. , 2000, The Journal of bone and joint surgery. British volume.

[28]  S. Aiso,et al.  Venous drainage of the distally based lesser saphenous-sural veno-neuroadipofascial pedicled fasciocutaneous flap: a radiographic perfusion study. , 1999, Plastic and reconstructive surgery.

[29]  C. Attinger Soft-tissue coverage for lower-extremity trauma. , 1995, The Orthopedic clinics of North America.

[30]  A. Masquelet,et al.  Skin Island Flaps Supplied by the Vascular Axis of the Sensitive Superficial Nerves: Anatomic Study and Clinical Experience in the Leg , 1992, Plastic and reconstructive surgery.

[31]  B. Pontén The fasciocutaneous flap: its use in soft tissue defects of the lower leg. , 1981, British journal of plastic surgery.

[32]  Sanjib Tripathee,et al.  How Safe Is Reverse Sural Flap?: A Systematic Review. , 2022, Eplasty.

[33]  I. Lascar,et al.  Reverse sural flap for ankle and heel soft tissues reconstruction , 2017, Journal of medicine and life.